Interactive Echo Case Discussion 2
GHA 10 / SHA 24 Joint Scientific Conference 13th-16th February 2013 Riyadh, Saudi Arabia
Flow in RVOT by PWD!
This Flow Was Picked Up From RVOT by CWD!
This Flow Was Picked Up From RVOT by CWD!
The Patient!
A male born 1992. Diagnosed with congenital heart disease 1994: S/P patch closure of VSD and PDA ligation 1997: S/P Ross procedure for aortic regurgitation and resection of SAM 2003: S/P balloon dilatation of homograft in pulmonary position 2009: Because of severe stenosis of pulmonary homograft, decision made for percutaneous intervention
Status 1: Prior to Intervention
Percutaneous Insertion of Medtronic Melody Prosthesis
Status 2: First Visit Post Prosthesis Insertion
Status 3: 3 Months Later
PR only in very early diastole Markedly raised RVEDP “halting” PR flow Also Ddiastolic forward flow into RVOT and “MPA”
Markedly raised RVEDP “halting” PR flow
PR only in very early diastole
Also diastolic forward flow into RVOT and “MPA”
Markedly Raised RVEDP
Markedly Raised RVEDP
CXR!
CT Scan!
CT Scan!
Surgery! Taken for emergency surgery The Melody prosthesis was removed and continuity between RVOT and “MPA” re-established with a conduit
Pathology
ď‚ž Biopsy
showed thrombus and aspergillosis!
Status 4: Post Surgery
A Similar but Chronic Case! 37 years old man Ross procedure September 2001 Regular follow-up Known to have relatively early degeneration of the homograft in the pulmonary position Conservative management initially as he was asymptomatic
Refused the surgery advised when felt needed ď‚ž Came with severe jaundice and significant right sided congestive heart failure ď‚ž
April 2002!
Pulmonary Valve
Tricuspid Regurgitation
December 2002!
Pulmonary Valve
Tricuspid Regurgitation
July 2003!
Pulmonary Valve
Tricuspid Regurgitation
2.4 m/sec 24 mm Hg
4.1 m/sec 67 mm Hg
4.1 m/sec 67 mm Hg
2.5 m/sec 27 mm Hg
TR October 2001
April 2002
P= 22 mm Hg M= 11 mm Hg
P= 87 mm Hg M= 51 mm Hg
December 2002
July 2003
PV P= 66 mm Hg M= 41 mm Hg
P= 52 mm Hg M=28 mm Hg
Post Surgery!
Take-Home Message! ď‚ž Be
wary of dropping gradients when it comes to stenotic AV valves! ď‚ž It may herald impairement of Ventricular function
Patient # 3
ď‚ž
A clue that ma help immediate postoperative care
Intraoperative Post AVR Doppler!
Peri-Operatively!
The Case!
Post Operatively Prior to Discharge S/P AVR (CM 21 mm!)